J Ayub Med Coll Abbottabad 2010;22(3)
KNOWLEDGE, ATTITUDES AND PRACTICES OF TYPE 2
Department of Medicine, Shifa College of Medicine Islamabad, Pakistan
Background: Education is the cornerstone of diabetes care. Because of lack of awareness, most
patients suffer from diabetes complications. This study was conducted to determine the knowledge,
attitudes and practices among patients with type 2 diabetes. Methods: This descriptive study included
one hundred type 2 diabetics. Patients were interviewed using a structured questionnaire. The mean age
of the patients was 50±5 years with the male to female ratio being 1:3. The data was collected using
convenience sampling technique and analyzed using statistical package Epi Info 6.0. The patients,
knowledge about the disease, their attitudes and practices were the main outcome measures. Results: In
our study, patients’ awareness about diabetes was low. The mean of correct answers for glycemic
control, risk factors and complications was 33.5%, 69% and 39% respectively. Sixty-one percent of the
patients regularly checked blood sugar but only few knew target blood glucose values. Only one sixth
of all the patients could correctly answer question regarding nutrition. 92% recognized blood pressure
as a risk factor while the correct answers for hyperlipedimia, cigarette smoking, sedentary life style and
body weight were 42%, 70%, 76% and 66% respectively. Awareness about eye and renal
complications was also quite low. Doctors were the main source of information available to the test
population. Conclusions: The knowledge, attitude and practice scores were low in most areas of
diabetes care emphasising the need for additional educational efforts.
Keywords: Type 2 diabetes, knowledge, attitudes, practices
Diabetes is a major and growing health problem
affecting more than 171 million people worldwide and
the number is expected to rise to 366 million by 2030.1
Type 2 Diabetes will continue to account for 90% of all
the cases. In Pakistan 9.5% of the urban and 9.4% of
the rural population suffer from type 2 diabetes. Overall
glucose intolerance (diabetes and impaired glucose
tolerance) is 22.04% in urban and 17.15% in rural
areas.2 According to the WHO estimates, Pakistan
ranked seventh in prevalence of Diabetes. These figures
however represent tip of the iceberg with many cases
Despite all the research, diabetes remains
under diagnosed. This then ultimately presents with
complications, the direct and indirect costs of which are
enormous.6,7 Diabetes care aims at improving the quality
of life of patients with type 2 diabetes through good
glycemic control8, control of risk factors, lifestyle
modification9,10, prevention of complications and
Diabetes education is the cornerstone of
diabetes care.12,13 Improved training of the primary
health care providers and patients with diabetes is
therefore beneficial.14 Several studies of family
physicians identified the need for improvement in their
practices for treating and educating diabetics.15,16 In
Pakistan, there is paucity of information about
knowledge and attitudes concerning glycemic control,
complications and the health impact of diabetes. There
are some studies from Karachi17 but data from other
regions of the country is sparse especially from
This study was designed to explore patients’
awareness about diabetes, misconceptions about the
disease itself, its treatment especially diet and insulin.
The information gained could subsequently be helpful to
design and initiate comprehensive programmes for
detection and control of diabetes and its complications
with self-care and community support as its major
MATERIAL AND METHODS
This study was conducted at the Department of
Medicine, Khyber Teaching Hospital Peshawar. A
questionnaire was designed which was pilot tested on 10
diabetic patients in the same hospital to assess the
suitability of content. Total study duration was 6 months
from August 2004 through February 2005. One hundred
consecutive patients with type 2 diabetes with disease
duration more than 1 year willing to participate in the
trial were included in the study. All patients with type 1
diabetes and patients with any major illness like cardiac
failure, chronic renal failure, and Psychiatric illness
were excluded from the study. Sampling technique was
non-probability (convenience) and study design was
Institutional review board approval was
obtained before starting data collection. After taking
consent, patients were interviewed in the out-patient
department in a comfortable environment. The
interviewer was well trained in using the questionnaire
J Ayub Med Coll Abbottabad 2010;22(3)
and knew the local languages. No interpreter was used.
Response rate was 100%. A structured Questionnaire
containing both open and close-ended questions was
used as a data collection tool. It was divided into five
main sections namely demographic data, knowledge
about diabetes and glycemic control, risk factors,
complications and miscellaneous. Patients who had not
received any education either at school or home were
included in the uneducated/illiterate group.
The data was tabulated and analysed using Epi
Info-6.0. The simple data analysis procedures like
percentages, means and ratios of the various variables
were calculated as per objectives of the study. The mean
age in years, male to female ratio and percentage of the
correct answers for diabetes and glycemic control
(diabetes meaning, blood glucose monitoring, target
blood glucose values, diet and drugs), risk factors
(hypertension, smoking, obesity and hyperlipidemia)
and complications (hypoglycemia, renal and
ophthalmological complications) were calculated.
Patients were given options for target fasting and
random blood sugar and target blood pressure and
diabetic diet. According to American diabetes
association guidelines16 target fasting blood sugar was
defined as 80–120 mg/dl and random blood sugar (2
hours after start of meal) as less than 160 mg/dl. Target
blood pressure was defined as less than 130/85 mmHg.
Diabetic diet was defined as balanced diet, low in sugar,
according to body weight. Percentage of the patients
who had received diabetes education and the main
source of information about diabetes were also
This study included 100 type 2 diabetic patients with the
disease duration ranging from one year to more than 10
years. Baseline characteristics (the mean age, duration
of disease, male to female ratio and educational level) of
the patients are shown in Table-1. Literacy rate was
lower in females compared to males. The results given
below are grouped into five main sections namely
patients general knowledge of diabetes, glycemic
control, risk factors, complications and miscellaneous
(source of information about diabetes, amount of time a
patient receives from a doctor in clinic and whether
there is a need for diabetes care centre at Khyber
Knowledge about diabetes was very poor.
The mean score (percent correct answers) for
glycemic control was 33.5% (minimum 17% to
maximum 61%). Table-2 summarises the response of
patients with respect to different aspects of glycemic
control. The knowledge about anti-diabetic drugs was
also low. Fifty eight percent of the patients knew that
diet, oral hypoglycemic drugs as well as insulin can
help control blood sugar while 42 (42%) of the
patients had no idea of insulin. Regarding patients’
attitude about diet 18 (18%) considered that balanced
diet low in sugar/sweets is important for diabetes
control while 52 (52%) thought that only sweets
should be stopped. Six percent were eating bitter
edibles to decrease their blood sugar.
The mean of correct answers for risk factors
was 69% (range 42% to 92%). Table-3 describes the
patients’ correct answers in percentage for health risk
factors like hypertension, hyperlipidemia, sedentary
lifestyle and cigarette smoking in a patient with type
In 23% of the patients, the first presentation
at the time of diagnosis was with complications. For
complications the mean score (percent correct
answers) was 39% (range 11% to 83%). Only 11
(11%) recognised yearly visits to ophthalmologist
important while 9 (9%) were of the opinion that they
should do consultation only when problem arises
Forty-five (45%) of the patients had ever
been educated about diabetes care and the main
source of information was a doctor in 78 (78%).
Media and relatives/friends were source of
information in 4 (4%) and 10 (10%) respectively. Of
those who had received diabetes education, 65 (65%)
received only 5 minutes from the doctor, while only 4
(4%) received more then 15 minutes. Sixty-five
(65%) of the patients strongly recommended that
there is a need for a diabetes care centre at Khyber
Teaching Hospital Peshawar.
Table-1: Characteristics of Type-2 Diabetics
Age (Years) Mean±SD
Mean duration of the disease (years)
Male to female ratio
Education level (% educated)
Table-2: Patient response for glycemic control in
Diabetes is a disease which can affect any part of
Diabetes is raised blood sugar only.
I don’t know what diabetes is.
Family members should be screened for diabetes.
Patients who check both fasting & random blood
Target fasting blood sugar (percent correct
Target random blood sugar (Percent correct
Patients who aimed target blood glucose.
Patients who can adjust anti-diabetic drug
according blood sugar level.
Diabetic diet (percent correct answers).
J Ayub Med Coll Abbottabad 2010;22(3)
Table-3: Knowledge, attitudes and practices of
patients regarding risk factors and complications
Blood pressure control is important for them
It is important to check serum lipids for a diabetic
Cigarette smoking is a risk factor for your health
Exercise help in blood sugar control
Patients who aim for target body weight
knowledge of target blood pressure (correct
Knowledge of Symptoms of hypoglycemia
It is important for diabetic to do renal function tests
The no. of patients who perform yearly renal
It is important to consult ophthalmologist
Patients who consult ophthalmologist yearly
Patients who carried a diabetes card/bracelet with
1=every 6 months, 2=once a year, 3=only when problem arises,
Figure-1: Patients who had an ophthalmologist
consult (The frequency of visits)
Diabetes is an important cause of morbidity and
mortality all over the world. Because of lack of
awareness about diabetes, most patients with diabetes
suffer from its complications.1
Almost half of the patients did not know as to
what diabetes is. This finding emphasises that the
average knowledge levels are low in communities with
higher diabetes prevalence.18,19 Most patients did not
realize the importance of screening other family
members for diabetes and this is probably one of the
reasons for a large number of people remaining
Sixty-one percent of the patients checked both
fasting and random blood sugar at least once a week
despite the fact that most of the patients were illiterate.
These data reveal better self monitoring when compared
with similar studies from Singapore 19 and even from
southern Pakistan.17 Of those who knew the blood
glucose targets only 60 (60%) had ever aimed to achieve
Only few could correctly answer questions
regarding dietary requirements in diabetes. This is much
less than the figures reported from Karachi.20 Poor state
of knowledge regarding nutrition has also been reported
in several other studies.21,22 This emphasises the need for
a dietician trained in diabetic diet to be an integral part
of the team. Patients with diabetes need to take safety
measures so that they can get early treatment in case of
emergencies. Diabetes bracelet/tag is one such measure.
Unfortunately 82 (82%) had no idea of it in the study.
Although most patients were aware of the risk
factors, only few knew the target values or tried to
achieve them. The average knowledge score regarding
various risk factors ranged from 40% to 92%. These
figures are comparable to the study results in Singapore
(31–91%).19 Only few knew the target blood pressure.
Less than half was aware of the importance of checking
serum lipids. The percentage of patients who recognised
cigarette smoking and sedentary life style as risk factors
is small. Obesity is risk factor for type 2 diabetes
mellitus and also over all cardiovascular health but the
study shows that only half aimed for target body weight.
About one quarter of the patients in our study
presented for the first time with complications. This
shows the lack of awareness in the general public about
diabetes. Only 11% thought yearly visits to
ophthalmologist important. Similar results are reported
from studies in the developing countries.22,23 In contrast
the knowledge level in certain developed countries has
been reported higher.24 Each year a number of patients
die of renal disease due to diabetes however the
awareness about it in our study patients was very low.
Half of the patients had never received any
education about diabetes. Of those who had been
educated about diabetes, report having received only
minimum time from the doctor that is 5 minutes because
of the rush in the out-patient department. This limitation
of health care facilities is perhaps an important factor
affecting the level of diabetes education. Most of the
patients thus strongly recommended the need for a
diabetes care centre. The main source of information
was a doctor. Most of the patients were illiterate. They
had knowledge scores slightly less than the readers.
Most of these patients were women and were less able
to put their knowledge into practice.
Our study has limitations due to convenience
sampling, which may limit generalisation of the
findings. Nevertheless, there is a need for education of
the doctors as well as the patients regarding diabetes
Diabetes education among patients with type 2 diabetes
is low in the cohort, emphasising the need for
multidisciplinary approach including a well trained
community doctor, dietician, diabetic nurse and a
community based education program. This is even more
important in a resource limited country like Pakistan.
This study can be conducted on a large scale in Pakistan
so that it is possible to design a diabetes awareness
J Ayub Med Coll Abbottabad 2010;22(3)
programme to promote prevention considering the
economic burden of the complications of diabetes.
Wild S, Roglic G, Green A, Sicree R, King H. Global
prevalence of diabetes–Estimates for the year 2000 and
projections for 2030. Diabetes Care 2004;27:1047–53.
Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in
Pakistan. Diabetes Res Clin Pract 2007;76:219–22.
Sheikh MZ. Diabetes Mellitus- The Continuing Challenge. J
Coll Physicians Surg Pak 2004;14:63.
Zhang X, Geiss LS, Cheng YJ, Beckless GL, Gregg EW,
Kahn HS. The missed patients with diabetes: how access to
health care affects the detection of diabetes. Diabetes Care
Rquibi M, Belasen R. Prevalence and associated risk factors
of undiagnosed diabetes among adult Moroccan Sahraoui
women. Public Health Nutr 2006;9:722–7.
Brandle M, Zhou H, Smith BRK, Marriot T, Burke R, Jabaei
BP, et al. The direct medical cost of type 2 diabetes. Diabetes
Kirigia JM, Sambo HB, Sambo LG, Barry SP. Economic
burden of diabetes mellitus in WHO African region. BMC Int
Health Hum Rights 2009;9:6.
Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HH.
10 year follow up of intensive glucose control in type 2
diabetes. N Engl J Med 2008;359:1577–89.
Johnson ST, Bell GJ, MCcargar LJ, Welsh RS, Bell RC.
Improved cardiovascular health following a progressive
walking and dietary intervention for type 2 diabetes. Diabetes
Obes Metab 2009;11:836–43.
10. Gutschall MP, Miller CK, Mitchell DC, Lawrence FR. A
randomized behavioral trial targeting glycemic index
improves dietary, weight and metabolic outcomes in patients
with type 2 diabetes. Public Health Nutr 2009;23:1–9.
11. Baradran HR, Knill-Jones RP, Wallia S, Rodgers A. A
controlled trial of the effectiveness of a diabetes education
programme in a multiethnic community in Glasgow. BMC
Public health 2006;6:134.
12. Peyrot M, Rubin RR, Funnell MM, Siminerio LM. Access to
diabetes self management education; Results of national
surveys of patients, educators and physicians. Diabetes Educ
2009;35(2):246–8, 252–6, 258–63.
13. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM,
Jenson B, et al. National standards for diabetes self
management education. Diabetes Care 2009;32(suppl
14. Van Zyl DG, Rheeder P. Survey on knowledge and attitudes
regarding diabetic inpatient management by medical and
nursing staff at kalafong hospital. J Endocrinol Metab
Diabetes South Africa 2008;13(3):90–7.
15. Shera AS, Jawad F, Basit A. Diabetes related knowledge,
attitude and practices of family physicians in Pakistan. J Pak
Med Assoc 2002;52:465–70.
16. American diabetes association. Standards of Medical care in
Diabetes. Diabetes Care 2009;32(suppl 1):S13–S61.
17. Jabbar A, Hameed A, Chawla R, Akhter J. how well do
Pakistani patients and physicians adhere to standards of
diabetes care. Int J Diabetes Dev Ctries 2007;27:93–6. [cited
2009 Aug 20]
18. Shah VN, Kamdar PK, Shah N. Assessing the knowledge
attitudes and practice of type 2 diabetes among patients of
Saurashtra region Gujrat. Int J Diabetes Dev Ctries
19. Tham KY, Ong JJY, Tan DkL, How KY. How much do
diabetic patients know about diabetes mellitus and
complications? Ann Acad Med Singapore 2004;33(4):503–9.
20. Jabbar A, Contractor Z, Ebrahim MA, Mahmood K. Standard
of knowledge about their disease among patients with
diabetes in Karachi, Pakistan. J Pak Med Assoc
21. Upadhyay DK, Palaian S, Shankar PR, Mishra P.
Knowledge, Attitude and Practice about Diabetes among
Diabetes Patients in Western Nepal. Rawal Med J
22. Rafique G, Azam SI, White F. Diabetes knowledge, beliefs
and practices among people with diabetes attending a
university hospital in Karachi, Pakistan. East Mediterr Health
J 2006; 12(5):590–8.
23. Murugesan N, Snehalatha C, Shobana R, Roglic G,
Ramachandran A. awareness about diabetes and its
complications in the general and diabetic population in a city
in southern India. Diabetes Res Clin Prac 2007;77:433–7.
24. Opalinska E, Strzemecka J, Latalski M, Goniewicz M. Health
behavior among patients with type 1 and 2 diabetes mellitus
reported to provincial diabetic outpatient department. Ann
Univ Mariae Curie Sklodowska 2003;58(2):64–70.
Address for Correspondence:
Dr. Naheed Gul, House 271, St-16, Sector G-10/2, Islamabad, Pakistan. Tel: +92-51-4603767, Cell: +92-321-5248081.